操作经验对超声引导下甲状腺结节细针穿刺活检的影响

The rate of no-diagnostic procedures and operator experience in ultrasound-guided fine.needle aspiration biopsy of the thyroid nodules

目的评估操作经验对超声引导下细针穿刺细胞学活检（US—GFNAB）无效率的影响。方法分析2008年2月至2012年4月，由一名超声科医师，应用22号或27号针，独立完成采样和制片的600次US—GFNAB甲状腺结节结果。由2名细胞学病理专家分析判读。600次操作按时间顺序分为6组（每组1013次），并按总体（A）、实性结节（B）、混合性结节（C）、纯囊性结节（D）、无细胞的样本（E）、血液污染样本（F）、完全胶体样本（G）、不正确制片样本（H）进行分层，划分有效或无效。结果学习曲线显示A—H层每层中1～6组的无效操作比率分别为：①A层：34％，15％，18％，10％，7％，8％。②B层：4％，l％，0％，0％，0％，0％。③C层：10％，1％，4％，0％，1％，0％。（够D层：20％，13％，14％，10％，6％，8％。⑤E层：25％，15％，15％，10％，6％，8％。⑥F层：4％，0％，1％，0％，0％，0％。（DG层：1％，0％，1％，0％，1％，0％。⑧H层：4％，0％，1％，0％，0％，0％。眩晕发作2例和4例活检部位中度出血，都自行处理，无严重并发症的记录。结论US—GFNAB至少有200次操作积累才能达到文献报道的诊断准确性水平，建议操作者在临床实践中专职执行此操作之前，先行定期的特殊训练。

Objective In clinical practice, ultrasound-guided fine-needle aspiration biopsy （US-G FNAB） is the gold standard in diagnosing the pathological nature of undetermined thyroid nodules before opera- tion. Results of FNAB may vary substantially among operators with different skills. The aim of this study is to e- valuate whether operator experience in US-G FNAB influences the rate of diagnostic procedures. Methods A to- tal of 600 consecutive US-guided FNAB done by a single radiologist with 22-or 27-gauge needles from Feb. 2008 to Apr. 2012 were retrospectively analyzed. All specimens were prepared and fixed without the cytologist on site and were subsequently analyzed by 2 expert cytologists. The procedures were chronologically divided into 6 groups and further stratified according to the overall （A） , solid nodules （ B ） , mixed nodules （ C ） , pure cystic nodules （ D）, acellular sample（ E）, heavily blood-stained sample（ F）, exclusively colloid material（ G）, incorrect slide fixation（H） and they were classified as diagnostic or no-diagnostic. Results The rate of no-diagnostic proce- dures for each group in learning curves were reported as： （1） Among A, 34% in group 1, 15% in group 2, 18% in group 3, 10% in group 4, 7% in group 5, and 8% in group 6. （2） Among B,4% in group 1, 1% in group 2, 0% in group 3, 0% in group 4, 0% in group 5, and 0% in group 6. （3） Among C,10% in group 1, 1% in group 2, 4% in group 3, 0% in group 4, 1% in group 5, and 0% in group 6. （4） Among D,20% in group 1, 13% in group 2, 14% in group 3, 10% in group 4, 6% in group 5, and 8% in group 6. （5） Among E,25% in group 1, 15% in group 2, 15% in group 3, 1% in group 4, 6% in group 5, and 8% in group 6. （6）Among F, 4% in group 1,0% in group 2, 1% in group 3, 0% in group 4, 0% in group 5, and 0% in group 6. （7） Among G,l% in group l, 0% in group 2, 1% in group 3, 0% in group 4, 1% in group 5, and 0% in group 6. （8） A- mong H,4% in group 1, 0% in group 2, 1% in group 3, 0% in group 4, 0% in group 5, and 0% in group 6. Among the 600 procedures, there were 2 cases of vertigo and 4 cases of moderate bleeding at the biopsy site, all of which resolved spontaneously. No major complications were recorded. Conclusions The rate of no-diagnostic US-guided FNAB is heavi- ly dependent on the operator＇s experience. We estimate that at least 200 procedures are needed in order to achieve the levels of diagnostic accuracy reported in the literature. We therefore suggest operators to get specific training before routinely perform this procedure in clinical practice.